JCAHO releases proposed goals

Hospital Pharmacy Regulation Report, March 1, 2005

Organizations must take precautions with IV connections

Hospitals will have to reduce the risk of wrong-tube, wrong-route intravenous (IV) connections and administration if a proposed 2006 National Patient Safety Goal becomes official, according to draft goals posted on the JCAHO Web site January 27.

Organizations had until February 25 to comment on the proposed goals. If the JCAHO sticks to past procedure, the Board of Commissioners will approve the goals this summer and they will become effective January 1, 2006 .

Wrong-tube, wrong-route connections and administration have been on the JCAHO's radar for some time. The commission has considered issuing a Sentinel Event Alert about the issue, said Richard Croteau, MD, the commission's executive director for strategic initiatives, during a recent teleconference.

Standardization leads to trouble

The problem with IV connections rests on one feature-standardized ports. These ports can lead staff to hook up an IV line to something meant for a catheter, says Rod Hicks, RN, MSN, MPA, research coordinator at the U.S. Pharmacopeia (USP) Center for the Advancement of Patient Safety (CAPS).

Manufacturers standardized IV ports when the International Organization for Standardization mandated several years ago that all tubing conform to the same benchmark, Hicks says. This way, if a hospital switches manufacturers, it won't have to spend money upgrading tubing and other equipment.

"The intent may be to access the IV port to give medications, but because the ports look alike, you may be accessing a port that is connected to the bladder catheter," Hicks says.

USP identified 300 cases of wrong-tube and interconnectivity errors from 1998 to 2003 in its MEDMARX error-reporting database, Hicks says.

Follow your lines

One potential error includes an epidural catheter inserted for anesthesia or pain control. Staff must insert the catheter into the central nervous system, usually the spinal column, and the catheter must be sterile, Hicks says.

USP has noticed cases in which staff have connected IVs to the epidural line and antibiotics have been delivered through the epidural catheter thereby increasing the potential for infection.

Tip: Trace the line from where the tube enters the patient's body to the point of origin. This will help staff see whether the tube is hooked up correctly, Hicks says.

Be careful with syringes

Another error USP researchers have found is in pediatric medicine. Sometimes staff push a syringe through an IV line, accidentally giving the patient medicine intravenously instead of orally, Hicks says.

Tip: Use an oral syringe, which is too large to connect to tubing, Hicks says. Hospitals would need to stock these, but they are inexpensive. The general public can purchase them at a local retail pharmacy.

See below for more examples of errors. Use them to educate staff to drive the point home, says Diane Cousins, RPh, vice president of CAPS.

"I think that's why the Joint Commission goal is so needed, because it will create awareness about what's gone wrong," Cousins says.

Use labels

Hospitals should also label IV tubes at the point at which they connect to the IV port, Cousins says.

"Some of these JCAHO goals might be a challenge to eliminate what they're addressing, but this is a preventable error," Cousins says.

Review other goals

Several other goal revisions affect medication use, including eliminating the use of multiple-dose vials, labeling mediation containers or other solutions, giving patients copies of their medication administration records, and eliminating harm associated with anticoagulants and narcotics.

Missing from the list is bar coding--a goal that was proposed last year for implementation in 2007, but didn't make the final cut for the 2005 goals.

"Bar coding is politically hot, and it's expensive from a capital expenditure standpoint," explains Robert Marder, MD, practice director for quality and patient safety for The Greeley Company, a division of HCPro.

Despite that, Marder believes bar coding may make a future list of goals, so organizations should keep the issue in mind.

The U.S. Pharmacopeia received the following cases involving tubing connections to its MEDMARX error-reporting database between 1998 and 2003:

Case 1: An intensive care nurse was caring for a patient with a ventricularostomy, drainage of the brain ventricles. The drain used standard intravenous (IV) extension tubing to connect the drain port to the collection bag. The nurse mistakenly connected a small infusion bag of antibiotics, commonly known as IV piggy-back, into the y-connector of the drain, infusing the antibiotic via the wrong route. The patient had to undergo additional monitoring as a result of the error.

Case 2: A postoperative patient had both an indwelling Foley catheter and a peripheral IV line. The physician ordered a continuous bladder irrigation for the indwelling Foley and maintenance fluid for the IV line. Using a dual-chamber infusion device, the staff connected the bladder infusion to the IV line. The error was discovered within a half hour. No patient harm was reported.

Case 3: In a similar case, another patient had both an indwelling Foley catheter with continuous bladder irrigation and a peripheral IV line. The routinely scheduled antibiotic was mixed in a small-volume infusion bag, and the infusion was initiated into the bladder irrigation tubing. No harm was reported in this patient.

Case 4: A patient had a nasogastric tube in place. The patient was scheduled to receive an intermittent dose of IV medications (famotidine). The IV medication was discovered infusing through the nasogastric tube rather than through an IV line. No patient harm was reported.

Case 5: In a labor and delivery setting, a patient had an epidural catheter line in place for pain control during the labor process. The nurse erroneously initiated a pitocin (a medication used to augment labor) infusion through the epidural line as oppos­ed to the peripheral IV catheter.

The error resulted in mild fetal distress and a decreased heart rate. The error resulted in prolonged hospitalization with increased observation and monitoring.

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